MEDICARE: REAL ESTATE 4000 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1619463023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REAL ESTATE 4000 LLC

Provider Business Mailing Address
First Line	:	27055 NORTHMORE ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-3643
Country	:	US
Telephone Number	:	313-377-5331
Fax Number	:

Provider Business Practice Location Address
First Line	:	19130 SUMPTER RD
Second Line	:
City	:	SUMPTER TWP
State	:	MI
Zip	:	48111-8724
Country	:	US
Telephone Number	:	313-485-1411
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	MRS. VALERIE MAKHOOL
Credential	:
Telephone Number	:	313-377-5331

Provider Enumeration Date	:	07/09/2018
Last Update Date	:	07/09/2018

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Directions to “REAL ESTATE 4000 LLC ” Practice Location

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